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	STATE OF MICHIGAN
RICK SNYDER	DEPARTMENT OF HEALTH AND HUMAN SERVICES	NICK LYON

GOVERNOR	LANSING	DIRECTOR

REQUEST TO DISCHARGE STATE-OWED DEBT

If you think you have good reasons for the Friend of the Court (FOC) to discharge (forgive or waive) your state-owed debt, please complete all information on this form, and return it to the FOC office where your court order is located. You may include more pages if you need more space. You may be asked to fill out more paperwork or provide proof of any of this information. FOC staff may schedule a follow-up meeting with you in person or by phone.

If you have a court order in more than one county, please provide a copy of this form to each FOC office where you are seeking discharge of state-owed debt.

PERSONAL INFORMATION

Name	Date of birth	Social Security number		Driver’s license or state ID number

Address

Email	Home phone		Cell phone

Custodial party name(s) or docket number(s) (if known)

YOUR SITUATION

Below, please list who lives with you in your household, including children.

Name	Age	How is this person related to you?	Does this person have income/
Name	Age	How is this person related to you?	help pay household expenses?
			help pay household expenses?
			Yes	No

			Yes	No

			Yes	No

			Yes	No

			Yes	No

			Yes	No

			Yes	No

1.In your living situation, do you: If other, please explain:

Rent

Own

Other

2.	Do you have any child support cases in other states?		Yes	No
	If yes, which state(s)?		Case number(s) if known:
3.	How much can you pay in current child support?	$		/month

4.	How much can you pay toward past-due support?	$		/month

5.Would you be able to pay at least $1,000 at one time if the FOC “matched” the payment amount by discharging an

equal amount of your state-owed debt?	Yes	No
DHS-681/FEN681 MS Word (Rev. 6-15)		1

If no, what amount could you pay all at one time to qualify for a matching discharge?

6.Please select your highest level of education:

Some high school	Two-year college degree (associate’s)
High school diploma/GED	Four-year college degree (bachelor’s)
Some college	Graduate degree (master’s, J.D., etc.)

7.Do you have any specialized job training or licenses (examples: apprenticeship, certification, etc.)?

Yes No

If yes, please describe:

8. Are you currently employed:

Full-time

If unemployed, are you eligible for unemployment benefits? If no, why not?

Part-time

Yes

Unemployed

If unemployed at any time in the past three years, please identify below which months you were unemployed and not receiving unemployment benefits. (You weren’t eligible for benefits, or they had run out.)

(Examples: 1/2011, 4/2012, etc.)

9.Current employer name and address, if you have one:

Employer phone:


10.	Are you currently incarcerated (in jail or prison)?	Yes		No
	If yes, please complete the following:
	Prisoner ID:
	Date you expect to be released:
	Date you expect to be released:
	Prison/Jail location:

11.	Have you been incarcerated in the past?	Yes		No
	If yes, please list approximate start and end dates:
	Start:		End:
	Start:		End:

Start:End:

12.If you answered yes to Question 11, is it hard for you to find employment because of previous jail, prison, or probation

sentences?

Yes

If yes, please explain:

DHS-681/FEN681 MS Word (Rev. 6-15)

13.	Are you receiving Social Security payments?				Yes	No
	If yes, please provide a copy of your award letter or other proof to the FOC with this form, and complete the following:
	Date you began receiving payments:
	Type of payments:		SSI	Disability		Retirement
	Are you permanently disabled according to the Social Security Administration (SSA)?						Yes	No
	If yes, please provide proof to the FOC with this form.

14.	Do you have a disability or other health issue(s) that may prevent you from working full-time, or from working at all?
	Yes	No
	If yes, please provide proof to the FOC with this form.

15.Do you currently receive public assistance (FIP, Medicaid, Food Stamps, etc.)?

Yes

	If yes, what kind of assistance?
16.	Are you currently under a bankruptcy plan, or are you in the process of filing for bankruptcy?			Yes		No

17.	Do you expect to receive money from a will, estate, or trust?	Yes	No

18.	Are you currently living in a homeless shelter or taking part in a homelessness program?			Yes	No
	If yes, length of time:

19.In the past six months, have you been unable to pay medical bills (for either yourself or a family member) that you

must pay?	Yes	No

20. In the past six months, have you been unable to pay other bills that you must pay?			Yes	No
If yes, list bills you are unable to pay:

21.Do you spend time with your child(ren) on a regular basis, attend school activities, and/or consistently exercise your

court-ordered parenting time?

Yes

22.In addition to your regular parenting time schedule, do you care for your children while the other parent is at work,

	at school, etc.?	Yes	No
	If yes, list how many hours you do this per week:

23.	Do you provide non-money support (examples: transportation, clothing, etc.) to your children?					Yes	No

24.	Would you be willing to take a finance or budget class?			Yes	No

25.	Would you be willing to attend a jobs program?			Yes	No

26.	Would you be willing to do volunteer work?			Yes	No
	If yes, how many hours per week are you willing to volunteer?

MONTHLY INCOME INFORMATION (List gross amounts – before taxes)

Income from job(s)	Workers’ compensation	Social Security (SSI, disability, retirement, etc.)	Veterans Administration (VA) benefits

Unemployment	Pension	Child support received (for all cases)	Spousal support

Settlement (legal settlement, insurance settlement, annuity)		Other income (describe source and monthly amount)

DHS-681/FEN681 MS Word (Rev. 6-15)

ASSET INFORMATION

Do you have a savings, checking, or other non-retirement account?

Yes

If yes, total amount in all accounts:

Date:

Bank or financial institution name:

Do you have retirement savings such as 401(k)?

Yes

If yes, total amount in all retirement accounts: $

Date:

Bank or financial institution name:

Do you own or lease a car or truck?

Yes

If yes, number of cars/trucks owned or leased:

Do you have any of these items worth over $500?

Computer/Tablet:

Yes

Snowmobile:

Yes

Boat:

Yes

Jewelry:

Yes

Camper:

Yes

Tools:

Yes

Motorcycle:

Yes

Other:

Yes

AVERAGE MONTHLY EXPENSES (your share or the amount you pay)

Rent/mortgage	Electric	Cable/satellite TV	Water
$	$	$	$
Natural gas/oil	Child support	Phone (home/cell)	Credit cards
$	$	$	$
Medical bills	Car payments	Child care	Education
$	$	$	$
Spousal support	Insurance (car, life, medical, homeowners)	Other monthly payment(s) (describe)
$	$		$

DEBTS (your share or the amount you pay)

Total balance on credit card(s)	Date	Total balance on medical bills (self)			Date		Total balance on medical bills (family) Date
$		$					$
Do you owe restitution as a result of a crime?			Yes	No		If yes, amount owed: $
Do you owe fees, fines, and/or court costs?			Yes	No		If yes, amount owed: $

Do you owe someone as a result of a court judgment?			Yes	No		If yes, amount owed: $

Please note that if any of your state-owed debt is discharged based on incorrect, incomplete, or false information you provided, the FOC may reinstate the debt forgiven (add it back to the total amount owed in support).

Please sign below to indicate that you believe the information you have provided on this form is correct and complete.

Signature

Print Name

Date

Michigan Department of Health and Human Services (MDHHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to an MDHHS office in your area.

DHS-681/FEN681 MS Word (Rev. 6-15)

Question	Answer
Form Name	Form Dhs 681
Form Length	4 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min
Other names	dhs 681 form michigan, mi dhs 681, mi dhs request debt form, dhs 681 print

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